Transcription

1 Farewell to Hippocrates: Medicine in the Information Age The Quality Colloquium at Harvard University Campus Aug. 21, 2008 Presented by: Michael L. Millenson, President and The Mervin Shalowitz, MD Visiting Scholar Kellogg School of Management, Northwestern University

2 The Hippocratic Oath I I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone In every house where I come I will enter only for the good of my patients. --Excerpt from Hippocratic Oath, c BCE 1

3 A Judgment-Based Culture The social obligation for best practice is part of the commodity the physician sells, even though it is a part that is not subject to thorough inspection by the buyer. -- Kenneth Arrow, PhD, Uncertainty and the Welfare Economics of Medical Care,1963 The application of knowledge at the bedside is largely the function of the sagacity inherent in or personally developed by the individual physician. -- Herman Blumgart, MD, Harvard University Medical School,

7 A New Social Context (The Hippocratic Loathe?) If there's one thing that can bankrupt the country, it's health care. It's out of control affecting our economic and national security. David Walker, Comptroller General, U.S. General Accountability Office Improving the performance of our health care system is without doubt one of the most important challenges our nation faces. Ben Bernanke, Chairman, Federal Reserve 6

10 An Intellectual Underpinning (Implicit AMA Approval?) A value-based [health-care] system is grounded in three simple principles: 1. The goal is value for patients 2. Care delivery is organized around medical conditions and care cycles 3. Results are measured Source: Porter and Teisberg, JAMA,

11 Ideologues Sing Chorus of Agreement That this country tolerates the very worst along with the very best quality of medical care, the poorly trained doctor along with the well-trained, those who overcharge along with those who charge reasonable fees, can best be explained by the total lack of information consumers have about doctors. -- Public Citizen Health Research Group, Jan. 17, 1974 (Mostly) Medicare has detailed information on nearly every doctor and hospital in the country. Americans have a right to know this information [on performance, cost and quality], and taxpayers must continue to demand its release. -- Newt Gingrich and David Merritt, Renew Milton Friedman s Conservatism, National Review, Dec. 4,

12 The Hard Work of Change To do things differently, we must see things differently. When we see things we haven t t noticed before, we can ask questions we didn t t know to ask before. --John Kelsch, Xerox To become competent, you have to feel bad. --Hubert Dreyfus, Philosopher 11

21 All Sorts of Media Are the Message America s 50 Best Hospitals National Examiner America s Best Hospitals -- US News & World Report Keys to finding the right physician -- Martha Stewart Living 20

22 Humor Sends a Message, Too Preparing for a Hospital Stay Preparing for a Hospital Stay When you arrive at your hospital room, decide which item you'd be willing to accept as the final thing you see on this earth. 21

33 Are your numbers better or worse? If you don t know the answer, why not? What will you do if someone (patient, health plan, employer, CMS, attorney) asks? What will be the consequences of your answer? 32

34 Money and the New Medicine Raise the standard of your work if you are expecting to raise your income. -- Charles Elton Blanchard, MD, Medical Dollars and Sense,

35 Medicare Leads the Way CMS Policy on Value-Based Payment Shift payment policy from volume Pay for quality care for a specific beneficiary not by provider type Pay for services across the continuum and not by location Reward systems and providers who efficiently provide service (quality and process management) Use IT innovation, traditional administrative data, and focused initiatives to support all three Source: CMS

41 You cannot solve the problems of the present with the solutions that produced them. -- Albert Einstein New Expectations, New Rules Who measures, matters Consumer-driven measures of clinical and service quality Peer assessment Payer-driven measures Regulators, accreditors, lawyers, reporters The customer is always right Physician-patient partnering Plan-physician partnering Hospital-physician partnering More and better team efforts 40

42 The Impact Transparency is triumphant Physician accountability Plan accountability Patient accountability The reality of change is complex Arguments about measures and money IT makes many things better, some things worse Reform gives way to uncomfortable transformation The Cottage Industry Collapses Paid like everyone else 41

43 Professionalism Redefined Trying harder will not work. Changing systems of care will. Institute of Medicine, 2001 As a result of the information revolution, the magic, mystery and power of the profession may be somewhat diminished, [but it] will create unanticipated opportunities for physicians to bolster the cognitive and moral pillars of their professional identities. David Blumenthal, Milbank Quarterly,

44 Hippocrates Returns (With an Economist) Information, in the form of skilled care, is precisely what is being bought [by the patient] from most physicians. -- Kenneth Arrow, 1963 There are, in effect, two things, to know and to believe one knows; to know is science; to believe one knows is ignorance. -- Hippocrates 43

45 21 st Century Health Care Improving quality by promoting a culture of safety through Value-Driven Health Care Information-rich, rich, patient- focused enterprises Evidence is continually refined as a by-product of care delivery 21 st Century Health Care Information and evidence transform interactions from reactive to proactive (benefits and harms) Actionable information available to Source: AHRQ clinicians AND patients just in time 44